HomeMy WebLinkAboutSeptic Pumping Slip - 2060 TURNPIKE STREET 5/16/2017 Commonwealth of Massachusetts
City/Town of North Andover RECEIVED
System Pumping Record j Ij t"'� 2 9 01
ti
Form 4 TOWN t�l[)()VER
DEP has provided this form for use by local Boards of Health. Other but the
information must be substantially the same as that provided here. Before using this form, check with your
local Board of Health to determine the form they use. The System Pumping Record must be submitted to
the local Board of Health or other approving authority within 14 days from the pumping date in
accordance with 310 CMR 15.351.
A. Facility Information
Important:When
filling out forms 1. System Location:
on the computer,
use only the tab 2060 Turnpike
key to move your Address
cursor-do not North Andover MA01845
use the return
key. City/Town State Zip Code ...........
Q2. System Owner:
Mansour Khani
Name
rehaa
Address(f different irom I-oc"-a-tion)"""", .............
City/Town State Zip Code
978-853-6987
Telephone Number
B. Pumping Record
1. Date of Pumping 5/16/2017 2. Quantity Pumped: 1500
Date Gallons
3. Type of system: Cesspool(s) 0 Septic Tank F1 Tight Tank ❑ Grease Trap
F] Other(describe): ..........
4. Effluent Tee Filter present? Yes No If yes, was it cleaned? Yes F1 No
5. Condition of System:
Good, system operati _pro erl
6. System Pumped By:
Jason Elliott571437
Name Vehicle License Number
Ivester and Elliott Services LLC-DBA Jason
Elliott Pumping
7. Location where contents were disposed:
jk
5/16/2017
Signa ure of Hauler Date
Signature o-f--Receiving Facility Date
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